Co-morbidity in Europe

Dr Alexander Baldacchino
University of Dundee/NHS Fife
Scotland

1st International Conference on Dual Diagnosis

Madrid: 19-20th April 2007
 Overview

Journey from the biological, psychological, epidemiological

and policy arenas

Dual Diagnosis; is it a virtual entity?

Neurobiological and neuropsychological issues

Psychopathological

Populations and co-morbidity: epidemiological issues

Service provision and policy issues

Vulnerability and resilience and co-morbidity

Chronic care model and co-morbidity

Implications for treatment: the way forward…
Neurobiology and neuropsychological issues
in dual diagnosis
Neurobiology and neuropsychological
issues in dual diagnosis

PFC
ACG
Amyg
NAcc
SCC Amyg
Underactive ACC in

adult ADHD patients

Neurobiology and neuropsychological
issues in dual diagnosis
Neurobiology and neuropsychological
issues in dual diagnosis
 Attentional Bias - Cue-Reactivity - Craving –
Relapse

Repeated Reward

Detection Threshold Disinhibition

Attentional Bias Cue-Reactivity Craving Relapse

Conflict Registration
 Psychpathology and comorbidity

Example: Cannabis and Psychosis in acute psychiatric
population

Literature review of all publications on cannabis and

psychosis using Cochrane techniques

EU Drug and Psychosis study (2001-2006)

Result: No difference in psychopathology between

individuals with cannabis psychosis and other types
of psychosis. Treatment is also no different. Same
treatment protocols
 Epidemiological studies and
comorbidity

(1) General populations:

ECA: 53% abuse drugs have MH problems

(current) and 32% (lifetime)

NEMESIS study 43%

Lifetime Prevalence and Odds Ratios of Mental
Disorders
by Substance Use Disorder: ECA
Alcohol Drug
Comorbid
Disorder % O.R. % O.R.
Any mental 36.6 2.3 53.1 4.5

Schizophrenia 3.8 3.3 6.8 6.2

Affective 13.4 1.9 26.4 4.7

Anxiety 19.4 1.5 28.3 2.5

Antisocial 14.3 21.0 17.8 13.8

(Regier et al., JAMA 264:2511-2518, 1990)

 Population studies

(2) Substance misuse population :

Cumulative 15%-93% !

(A) Personality disorders (65%-85%)

(B) Affective disorder (30%-55%)
(C) Psychotic disorders (20%)
 Population studies

(A) Substance misuse population: personality
disorders
Verhaul (2000) 187 drug dependent in Holland: 23%
APD, 18% BPD (lifetime)
Fridell (1996) 1052 polydrug dependent in Sweden:
23% APD (current)
Frei (2002) 85 Heroin assisted in Switzerland: 58%
PD (lifetime)
Nielson (2002) 104 alcohol dependent in Denmark:
50% APD and 30% BPD (current)
 Population studies

(B) Substance misuse population: affective
disorders (anxiety and depression)

Siliqiuni (2002) 58 drug users in Italy: 23% mood

and 21% anxiety (current)
Tomasson (1995) 351 polydrug users in Iceland:
33% mood and 65% anxiety (lifetime)
Enatescu (2006) 304 drug and alcohol dependent:
12% mixed anxiety and depression (lifetime)
 Population studies

(C) Substance misuse population: affective
disorders (psychotic including schizophrenia)

Kokkevi (1995) 176 opioid users in Greece: 6%

schizophrenia (lifetime)
Facy (1999) 3936 methadone users in France : 1.6%
psychosis
Weaver (2003) 278 polydrug users in England: 8%
psychosis (one year)
 Population studies

(3) Psychiatric populations

(Drugs and alcohol)

Current: ~11.8% - 45%
6 months: ~15%
One year: ~15% - 44 %
Lifetime: ~22% - 74%
 Population studies

(4) Other vulnerable populations:

(A) Young People:

Hannesdottir (2001) 103 adolescents for

detox: 75% co-morbidity
 Population studies

Other vulnerable populations:

(B) Homeless
Kershaw (2000) 22% in Glasgow homeless
Reinking (2001) 27% of Dutch homeless
 Population studies

Other vulnerable populations:

(C) Prisoners:
Singleton (1998) 81% in remand with co-
morbidity
 Population studies

Other vulnerable populations:

(D) Street workers/Prostitutes

Gilchrist (2004) 70% current co-morbidity
 Epidemiological studies

Methodological issues to consider:
(a) Definitions
(b) Exclusion and inclusion of groups
(c) Instruments used
(d) Settings and types of interventions
(e) Time window
(f) Context (ethos and philosophies of care)
 Epidemiological Studies
Key patterns from epidemiologic data

Comorbidity is the rule rather than the exception

Cross-cultural findings show that the magnitude of

comorbidity is more similar than are the differences
in baseline prevalence

Risk for drug dependence > drug abuse

Risk varies by mental disorder (Anxiety < Mood <

ASPD)

Risk varies by gender (female > male)

Risk varies somewhat by specific drug disorder and

number of drug disorders
 Policy and Comorbidity:
The Scottish National Comorbidity
Study

Identification of needs

Service User experiences

Current provision in relation to needs

Relations between services

Examples of good practice

 Methodologies

Structured interviews with commissioners of

services

In-depth Interviewing with service users

Focus groups with coalface staff

Framework Analysis (Ritchie & Spencer, 1994)

 Identified Gaps
Access
Lack of one-to-one

Lack of signposting
Traditional professional

Structural obstacles trajectories

Eligibility criteria

Capacity Service organization

Expertise in co-morbidity
Service response

Bureaucracy

Inflexibility

Exclusion

Continuity

Stigma
 From Pillar to Post

“I went there [local Drug Problems Service]
and just got referred back to the hospital
and when I was in the hospital they said
look we cannae dae nothing for you, you’re
gonna have to get treated by the Drug
Problems Service and then they [local Drug
Problem Service] just say go back to my ain
doctor and try to get something sorted out”
 A Clear Path Through the Maze?
“Integrated care pathways work well when you’ve got a
history or a natural course of a disease or the process
is clearly understood. Once you get beyond something
as simple as an acute episode, integrated care
pathways don’t follow linear trajectories. We make the
assumption that somehow we can create a pathway
that zigzags between all of these possible sources of
service. Even then they would work if we had people
capable of keeping track of their own care
requirements. So if the person who has a mental
illness plus another problem related to substance
misuse could actually manage their own way through
that system that would be simple and straightforward.
They can’t.”
 Stickiness!

“I think X is the best because they get a hold o’ ye and keep
pursuing ye until they get ye. Some days I don’t come but they’re
persistent tae get a hold o’ ye and they go looking for ye tae yer
friend’s hoose or your ma’s hoose or your family’s hoose looking for
ye, somebody’s there fer ye”

“My key workers are constantly in touch and talking about where
they think I should be going or what I should be doing or how I’m
doing”

“They [Key workers] end up moving on and the case doesn’t get
picked up or if you dae get picked up you get picked up by five
different people, then I got five CPNs in a row. I couldnae work with
like five different people I find it hard enough to trust one person
over a long period of time then to be asked to be moved to another
person in two weeks, on to another person and then another it’s just
impossible”
 Specialists or Specialist Services?

“It [specialist comorbidity service] doesn’t

seem to work well for us. It’s certainly not
knitted in well to the mental health system,
not knitted into the addiction system, so the
classic thing is you create a specialist
service which has defined its own role
existing in splendid isolation.”
Co-morbid Mental Health and
Substance Misuse in Scotland
Claire-Louise Hodges
Sheila Paterson
Matira Taikato
Sarah McGarrol
Ilana Crome
Alex Baldacchino

May 2006

Scottish Executive Social Research

Substance Misuse Research
Programme
 ISADORA: Integrated Services Aimed at Dual Diagnosis and
Optimal Recovery from Addiction

Establissement de santé Maison-Blanche, Paris, France

University of Tampere, Finland

University of Dundee, Scotland

Institute of Psychiatry and Neurology, Warsaw, Poland

Middlesex University, London, England

Cambridge University, England

The Psychiatric Services in the County of Aarhus,
Denmark
ISADORA: Integrated Services Aimed at Dual Diagnosis
and Optimal Recovery from Addiction

To describe the psychiatric service opportunities

for treatment

To determine and compare the co-morbidity
pattern

To follow-up a cohort of patients

To identify predictors of prognosis

To explore the views of dual diagnosis patients
and of staff

To use study results as a basis for developing
an educational programme

To develop common assessment instruments
 Methodology of the study

A descriptive study of treatment

opportunities

A descriptive study of the pathway
through care

A follow-up study

An exploration of the views of staff

A study of risk factors

A development of an educational
programme for staff
34
 ISADORA

A cohort study: 50/site, F30-33.9 (350)

Case studies (20)

Focus group interviews: service users and
providers (12)

Epidemiological data (local/regional)

35
 Service mapping and service users’
perspectives: ISADORA (1)

Lack of coordination

Improved signposting

Lead clinicians are often absent from case conferences

Structural and procedural changes militate against effective
networking

Client autonomy and choice may inhibit referral processes

Feedback is limited

Confidentiality issues

Complexity for the sake of it
Service mapping and Service users’
perspectives: ISADORA (2)

Lack of designated time for network

development/joint working

Ignorance regarding others’ roles and remits

Attitudinal barriers

Different professional silos and

Different clinical approaches e.g. medical versus
social models

Lack of expertise on dual diagnosis and on how
best to network
Service mapping and Service users’
perspectives: ISADORA (3)

Clients often miss appointments leading to
discordance and discontinuity

Geographical spread of services creates logistical
problems

Staff turnover

Unclear who should take primary responsibility for
DD clients

Lack of tolerance for substance misuse creates
barriers to appropriate care

Waiting times and bureaucracy cause lengthy
delays and fragmentation
ISADORA: Contact to services (psychiatric, substance use,
social and medical) at different research sites at baseline, 3,
6 and 9 month f/up
contact with 4 areas
4,00 of services (soc.,
med., smu., psych.)
baseline
contact with 4 areas
of services (soc.,
med., smu., psych.) 3
months follow up
3,00 contact with 4 areas
of services (soc.,
med., smu., psych.) 6
months follow up
contact with 4 areas
of services (soc.,
med., smu., psych.) 9
Mean

2,00 months follow up

1,00

0,00

Aarhus Paris Tampere Dundee Warsaw Middlesex Cambridge

site
 ISADORA

Long-term planning is needed beginning at a
policy level supported by chief clinical leads and
commissioners and underpinned by good practice

The voluntary sector should be developed to
improve capacity. Integrated services more user
friendly and better retention. Quality rather than
type of service important

System needs to be more flexible. The more
contact patients have the more contact at follow
up with resulting positive outcomes in most
domains including psychopathology

Improved deployment and increase of resources
needed. Site most resources is site with better
retention and outcomes
 Way forward………..

Another way of looking at co-
morbidity ?

Microsystem (vulnerability and

resilience)

Macrosystem (chronic care models)

 : Vulnerability and resilience
Exploring concepts of mental health and
substance misuse:
Never culture free
Never morally and ethically neutral

What we understand or want to understand of

co-morbid substance misuse and mental
health will depend on:………..
 Vulnerability and resilience and co-
morbidity

Our values

Preconceptions and assumptions on:

(a) Nature of health and illness

(b) Nature of society
(c) Place of the individual within society (normality)
(d) Desirable behaviours

This is either indicative of diversity or an excuse to exclude

due to its complex nature
 Vulnerability and resilience and co-
morbidity

Vulnerability

We are all vulnerable

Much human effort is dedicated in managing
that uncertainty in order to reduce or remove
vulnerability

Nature and nurture
 Vulnerability and resilience and co-
morbidity

It is a function of susceptibility to loss and
the capacity to recover. This capacity is
termed resilience

Resilience is the ability to cope from
adverse events

Not a justification for labelling and stigma
but an opportunity to identify communities
and groups most in need
 Vulnerability and resilience and co-
morbidity
Potential indicators:

Livelihood security (wealth, income)

Access to crisis support

Housing quality

Psychological state :
(a) Strong coping and problem solving abilities/skills
and role models
(b) Awareness of personal networks and stable
emotional relationship
 Vulnerability and resilience
(c) Internal locus of control
(d) Positive cognitions
(e) Life events (intrauterine, postnatal and beyond)
(f) A sense of humour!

Well being (good physical health and lack of

chronicity)

Local economic security (social capital)

Employment and education

Environmental minority groups with no ‘rights’ or
avenues for justice
 Vulnerability and resilience and co-
morbidity
Linked to concepts of emotional intelligence, self
regulation, social competence and self
organisation

The social and biological factors are very closely

interlinked but still do not know enough

It is not a set of static protective factors but a

dynamic one that include accumulated and
multiple risks at a point in
time………………….Role of assessments
Chronic disease/care model and co-
morbidity

Current view of health and social care

Geared towards acute conditions

Hospital centred

Doctor dependent

Episodic and disjointed and/or reactive care

Patient passive with self care infrequent

Carers undervalued

Low technology (databases, evaluation etc)
Chronic disease/care model and co-
morbidity
Evolving model of chronic care

Geared towards long term conditions

Embedded in communities

Team based

Continuous care

Integrated care

Preventative care

Patient/client as partner

Self care encouraged and facilitated
Chronic disease/care model and co-
morbidity

15th November 2005

Chronic disease/care model and co-
morbidity
Chronic disease/care model and co-
morbidity

Relapse rates for drug addiction are similar
to other chronic medical conditions

Mental illness and substance misuse are
chronic relapsing conditions

Co-morbid substance misuse and mental
health problems are 2 co-existent chronic
care conditions
Chronic disease/care model and co-
morbidity

Looking at co-morbidity as another aspect of
the overall chronic disease model will
demystify the ‘complexity’ of the condition

This will then be seen as a situation that is
similar to diabetes, cardiovascular disorders
and other conditions that merits adequate
resources and integrated approaches
Chronic disease/care model and co-
morbidity

This will change the way we intervene,
treat and evaluate co-morbid conditions

Treatment should be:
(a) Ongoing
(b) Prioritised
(c) Encourage patient/client to participate in
their own recovery (self management)
Chronic disease/care model and co-
morbidity
(a) Enable partnerships based on competencies
(b) Based on evidence based guidelines
(c) Integrated specialist expertise and primary care
(d) Identify high risk groups with proactive care
(e) Facilitate individualised patient/client care
planning
(f) Approach evaluation as a chronic care co-
morbidity system
 Conclusion

Co-morbidity assessment and treatment
interventions needs to look at:

The individual’s and populations/groups resilience

against co-morbidity in order to treat proactively

Use the chronic disease processes to plan
delivery of health and social care for
individuals/groups with co-morbid conditions
 Recommendations
(A) Strategic Plan

A national strategy

Agreed definitions and overall model of care

Joined up provision

Greater integration of mental health and
substance misuse services

Development of policies, protocols and procedures

Commissioning:
 Recommendations
(B) Operational

Stigma and prejudice

Health promotion

Means and mechanisms

Accessibility

Education, training, employment

Ethnic minorities

Carer support
 Recommendations
(C) Training and education

Defining the objective

Training needs analysis

Education:

Training resources

Face-to-face

Special groups

Childhood trauma

Other relevant organisations
 Recommendations
(D) Clinical

Inclusivity rather than exclusivity

Ethos and philosophy

Needs-led rather than service-led

Assessment framework

Development of a user-friendly screening and assessment
tool

Working with childhood trauma

Care planning

Provision of the range of psychological and
pharmacological interventions:
 Recommendations
(E) Research

Understanding and enhancing the
effectiveness of treatment interventions

Service development models

Specific (generally hard to reach)
populations

Research on different patterns of co-
morbidities
A note of caution
Another note of caution….
 Thank you:
a.baldacchino@dundee.ac.uk